Appendix E.10 Parental Consent to Interview Child or Teen Revised

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix E-10.

Parental Permission Form: Consent for Child to Participate in the

Summer Meals Study Pretest

Your child is being asked to take part in a research study conducted by the U.S. Department of Agriculture (USDA) Food and Nutrition Services (FNS). This study is to help us test questions which will be included in a survey of children about the Summer Meals Programs. These programs provide meals and snacks to children in low-income areas during the summer months when school is not in session.

This consent form tells you about the study and what your child will be asked to do. The study is voluntary – you can choose to allow your child to take part in the study or not. If you agree to allow your child to participate, we will ask your child questions from the survey. Then, we will ask your child what he or she thinks about the questions. The questions that we’ll ask are thoughts and reactions to the questions. Your child’s interview session will help us improve the survey questions. If you choose to allow your child to take part, you will need to sign this form.

Your child’s interview will last about 30 minutes. The interview will be audio recorded and notes will be taken. In addition, project researchers may be observing. The audio recording of this interview will be destroyed at the end of the study.

• Your child’s participation is completely voluntary. He/She may stop at any time, and does not have to answer any questions he/she does not wish to answer.

• His/Her responses will be used for question evaluation only and may not be disclosed, or used, in identifiable form for any other purpose.

• There are no direct benefits to your child for participating in this study. However, he/she will be helping with an important research project.

• We will also ask your child for his/her agreement to participate in the interview. He/She may choose not to participate even if you give your approval by signing this permission form.

• There are no known risks associated with taking part in this interview. All the data we collect will be kept private and will not be disclosed to anyone outside of the research team, except as otherwise required by law. Your child will not be identified by name in any of our summaries or reports. Their name will not be linked to any of their responses, though we may include quotes they provide in our reports. Their information will be combined with information from other respondents and presented in summary form.

• If you child chooses to take part in the session you will receive $30 cash, on your child’s behalf, as a token of our appreciation.

If you have any questions about this study, please call [NAME] at [TELEPHONE NUMBER]. If you have questions about your child’s rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about the “SUMMER MEALS STUDY”, and a phone number beginning with the area code. Someone will return your call as soon as possible.

If you agree that your child may participate in this interview, please sign the following statement:

I have read this consent form and understand the proposed project. I consent to my child participating in this study.

I have read the information contained in this permissions form and:

• Yes, I give my permission for you to ask my child to take part in this research study.

• Yes, I allow the researchers to record my child’s interview.

Print Child’s Name: ________________________________________________

Print Parent / Legal Guardian Name: ___________________________________________

Parent / Legal Guardian Signature: _________________________________________

Date: ___________________

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.